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��� � � � � <br /> ��� Applica#ion for Exemption � Fo�M <br /> Ne4raska papartmen[of <br /> pc�l►11 1E from Motor Vehicle Taxes by Qualifying Nonprofit Organizations 45� <br /> I1G 111 V •To be filed with your caunty treasurer. <br /> •Read instructions on reverse side. <br /> ApplicanT's Name Type of Uwnership <br /> ��l a' ,v'���0.S IC0. � i u� a.' �C- V•� � rn�` [�]K Nonprofit <br /> Sireet ar�ther MaiGng Address County q Corporation <br /> �s 3�r c0.,r1'�t�K 'C v�.. 1a0.1� ❑Other(Sp��Y�: <br /> piry Stats 2ip Gode . State Where Incorporated <br /> ra�..d I 1 �. � � 6 � So3 tiJE <br /> IDENTIFY OFFICERS,�IRECTORS,OR PAI�TN�RS QF THE NONPRpFl7 ORGANIZATION <br /> Title Name,Address,City,State,Zip Gode <br /> � ( � 0SS r, n /l1� G8 a ( <br /> V ' c C.h ir r.� S t x 1��1. G� 6bo NE 6 80�.1 <br /> 5�� / Tr ect 5 c.�r�r +� e� �lo�� K Sh. Ur� � 6 S� tQ �. <br /> G E d Q i�nti Co..m l I(� �v e.nv�,t Nq s�; � 6 8 �Q / <br /> D�SCRIPTIdN OFTHE MOTOR VEMICLES <br /> •Attach an additional sheet,if necessary. <br /> Reglstration Date or <br /> MotGrVehiole Make ModelYear 6adyType Vehicle Ib Number Date of Acquisition, <br /> ii Newl Purchased <br /> Go a Il F0��4FS�4D �. G86 r- r8 -iz <br /> Exempt Uses oC Motor Vehide: Are the motor vehicles used exclusively <br /> �AgriculturaVHorticultural ❑Educational ❑Religious �CharitaWe ❑Cemetery as indicated? <br /> Give detailed description of use,including an explanation it mWtiple use classifications exisl: [�Y�S �NO <br /> �o firo�-an5�or�` �@.U+e.lo�J h'l�i'o..l� y c� iSct.t7`� IfNo,give��e�� <br /> .1 ` <br /> i n� �v� c� n�a-� 5 . <br /> �a� � s �o�z <br /> Under penalties of law,I declsre ihat I have examined this application and that k is,to the best of my knowledge and bel f,vue,comp�,� ��y� <br /> also daclare that I am duly authorized to sign this exemption application,and ihat the organization owning fhe abov�list ra n (q(g��,� ��RA�KA <br /> in memhership or empbyment based on race,color,or national origin. <br /> � . <br /> s i g n � � A t"��. �1J �rt��O r 1� t 7— <br /> here t rizedSgnature ` Title Oate <br /> FQR COUNTY7REASURER RECQMMENDATION <br /> [�-,4PPROVAL COMMENTS: b� <br /> ❑DISAPPFtOVAL - <br /> " `� %�- a �--�� <br /> Sgnature of County Veasurer pate <br /> FDR COUNTY 80ARD OF E�UALIZATION USE ONLY <br /> �APPROVAI� COMMENTS: <br /> ❑�ISAPPROVAL <br /> �/-- U <br /> - thorize Signa u Date <br /> Nebraska Department of Revenue AulYwnzed by Na6.Rev.Stat.§§77-202(1)(c)and(d),and 6a3,185,and 603,169 <br /> 96-253-2006 Rev.8-2011 Supersedes 96-253•2otl6 Ciev.5-2009 <br /> PL�ASE RETAIN A COPY FORYOUR RECORDS. <br /> � <br />